Geographic location often determine access, quality of U.S. child healthcare

While 28 million children are covered by Medicaid and six million are covered by the State Children's Health Insurance Program (SCHIP), some states do better than others in promoting the health and development of their youngest residents, according to a new report from the Commonwealth Fund Commission.

The “State Scorecard on Health System Performance” report found that healthcare access, as well as healthcare quality, costs, outcomes and equity, varies widely across the United States. The report examined performance variations among states’ child health systems, building on many of the State Scorecard indicators as well as other key indicators of children’s health.

The fund found similar variation in performance among states and abundant opportunities for all states to improve. With a goal of focusing on improvement opportunities, the report analysis assesses performance relative to what is achievable, based on benchmarks drawn from the range of state health system performance.

The report focused on 13 indicators of child health system performance along the dimensions of access, quality, costs and the “potential to lead healthy lives” in all 50 states, plus the District of Columbia. Also, for two indicators, gaps in performance by income, race/ethnicity, and insurance were used to gauge equity.

The report highlights variations in state child health system performance point to six important findings:

High performance is possible: Iowa and Vermont have created children’s healthcare systems that are accessible, equitable and deliver high-quality care, while controlling levels of spending and family health insurance premiums. In the last decade, both states have adopted policies to expand children's access and improve their quality of care. Iowa and Vermont expanded SCHIP and mandated that all child health plans and local and regional children's health systems publicly report data on the quality of care.

Leading states consistently outperform lagging states on multiple child health indicators and dimensions: 13 states—Iowa, Vermont, Maine, Massachusetts, New Hampshire, Ohio, Hawaii, Rhode Island, Kentucky, Kansas, Wisconsin, Michigan and Nebraska—emerge at the top quartile of the overall performance rankings. Conversely, the report said child uninsured rates in these states are well above national averages, and more than double those in the quartile with the lowest rates.

There is wide variation in child access to quality healthcare across the United States: The proportion of children who are uninsured ranges from 5 percent in Michigan to 20 percent in Texas. The proportion of children who have regular medical and dental preventive care ranges from 75 percent in Massachusetts to 46 percent in Idaho. The proportion of children hospitalized for asthma ranges from 55 per 100,000 children in Vermont to 314 per 100,000 in South Carolina.

Children's access to medical homes—primary care providers who deliver healthcare services that are easily accessible, family-centered, continuous, comprehensive, coordinated and culturally competent—varies widely: 61 percent of children in New Hampshire, and more than half of all children in all the New England states, have a medical home, compared with only one-third in Mississippi. Research shows that medical homes are an effective way to improve healthcare quality and reduce disparities by race, insurance status and income.

Across states, better access to care is closely associated with better quality of care: Seven states—Rhode Island, Wisconsin, Iowa, Michigan, Connecticut, Vermont, and New Hampshire—are national leaders in giving children access to care and ensuring high-quality care.

There are strong regional patterns in child health system performance: New England and the North-Central states perform well on indicators of healthcare access, quality and equity, while many western and southern states have lower healthcare costs. New England, Upper Midwest, East North-Central and West North-Central states perform well on indicators measuring the potential for children to lead healthy lives.

The report revealed critical areas in which state and federal policies are needed to improve child health system performance for all U.S. families. States that invest in children's health reap the benefits of having children who are able to learn in school and become healthy, productive adults. Other states can learn from models of high performance to shape policies that ensure all children are given the opportunity to lead long, healthy lives and realize their potential, according to the fund.

Also, the fund said that investment in children’s healthcare measurement and data collection at the state level could enrich understanding of variations in child health system performance. For many dimensions, only a limited set of indicators is available.

In the case of costs, measures used in the report are for the total population and not specific to children. The indicators of child healthcare quality presented here are largely parent-reported; however, data on clinical quality are necessary to paint a clear picture of state child health quality, according to the report.

Thus, the fund noted that the collection of clinical data for children’s healthcare quality is integral to future state and federal child health policy reform and could modify the state rankings provided in the report.